EMDR Research News August 2013

Here are this month’s recently published, peer-reviewed journal articles related to EMDR. This month there are three new articles. In the first of these, de Jong et al. (2013) compare the effectiveness of EMDR with bilateral eye movements or tones with recall only (watching a blank wall) in a “real world” study from the clinical practices of Dutch EMDR therapists. Interestingly they found equivalent benefits for those with either PTSD or other diagnoses. Clinicians and clients who prefer bilateral tones to eye movements, may find the results of this "real world" study challenge their assumptions. Read the abstract below for the provocative results. Then there are two review articles. In the first, Gillies et al. (2013) publish their review of psychological therapies for PTSD in children and adolescents. In the second, Verstrael et al. (2013) report their meta-analysis of (EMDR) as treatment for combat-related PTSD. In both cases, the findings make it clear that there needs to be much more research with EMDR.

On a brighter note, the World Health Organization released new clinical protocols and guidelines to health-care workers which recognize both EMDR and trauma focused CBT for treating the mental health consequences of trauma and loss in children, adolescents, and adults. Below the break you will find how to get free PDF copies and a short commentary on their findings.

This month as a change from a video of the month, I am bringing you a link to a National Public Radio interview by Krista Trippett from July 11, 2013 "Restoring the Body: Bessel van der Kolk on Yoga, EMDR and Treating Trauma.”With each reference below, you will find the citation, abstract and author contact information (when available). Prior quarterly summaries of journal articles can be found on the EMDRIA website and a comprehensive listing of all EMDR-related research is available at the Francine Shapiro Library. EMDRIA members can access recent Journal of EMDR Practice and Research articles in the member’s area on the EMDRIA website. JEMDR issues older than 12 months are available open access on IngentaConnect.

Audio of the month

This month, we feature a National Public Radio On Being interview by Krista Trippett from July 11, 2013 "Restoring the Body: Bessel van der Kolk on Yoga, EMDR and Treating Trauma”. Quoting from the On Being blog: “Human memory is a sensory experience says psychiatrist Bessel van der Kolk. Through his longtime research and innovation in trauma treatment, he shares what he's learning about how bodywork like yoga or eye movement therapy can restore a sense of goodness and safety. And what he’s learning speaks to a resilience we can all cultivate in the face of the overwhelming events that after all make up the drama of culture, of news, of life.”

World Health Organization Guidelines for the management of conditions specifically related to stress

On August 6, 2013, the World Health Organization released new clinical protocols and guidelines to health-care workers which recognize both EMDR and trauma focused CBT for treating the mental health consequences of trauma and loss in adults.

WHO has published two guidelines. The first, the mhGAP Intervention Guide Module. recognizes both EMDR and CBT under the Advanced Psychological Interventions and points out that, "Unlike CBT-T, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure or (d) homework."

The second, and longer Guidelines for the management of conditions specifically related to stress recommend EMDR and trauma focused CBT for treatment of posttraumatic stress disorder for children, adolescents, and adults, to be used "only in those contexts where individuals are competent (i.e. trained and supervised) to provide the therapies." While this endorsement of EMDR is certainly welcome news, the WHO Guidelines found insufficient evidence to recommend EMDR for the treatment of acute stress disorder or bereavement. More research is needed in these areas.

Background: A wide array of experimental studies are supportive of a working memory explanation for the effects of eye movements in EMDR therapy. The working memory account predicts that, as a consequence of competition in working memory, traumatic memories lose their emotional charge. Method: This study was aimed at investigating (1) the effects of taxing the working memory, as applied in EMDR, during recall of negative memories in 32 patients with posttraumatic stress disorder (PTSD), and 32 patients with other mental disorders, and (2) whether the results would differ between both groups. In a therapeutic session patients were asked to recollect a crucial upsetting memory while, in counterbalanced order (a) performing eye movements, (b) listening to tones and (c) watching a blank wall (‘recall only’), each episode lasting 6 min.

Results: Eye movements were found to be more effective in diminishing the emotionality of the memory than ‘recall only’. There was a trend showing that tones were less effective than eye movements, but more effective than ‘recall only’. The majority of patients (64%) preferred tones to continue with. The effects of taxing working memory on disturbing memories did not differ between PTSD patients and those diagnosed with other conditions.Conclusions: The findings provide further evidence for the value of employing eye movements in EMDR treatments. The results also support the notion that EMDR is a suitable option for resolving disturbing memories underlying a broader range of mental health problems than PTSD alone.

BACKGROUND: Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES: To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SELECTION CRITERIA: All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS: Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team. We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS: Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy. Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group. The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified. No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS: There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others. The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses. More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

PLAIN LANGUAGE SUMMARY: Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. The aim of this review was to examine the effectiveness of all psychological therapies for the treatment of PTSD in children and adolescents. We searched for all randomised controlled trials comparing psychological therapies to a control, other psychological therapies or other therapies for the treatment of PTSD in children and adolescents aged 3 to 18 years. We identified 14 studies with a total of 758 participants. The types of trauma related to the PTSD were sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in the included studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most included studies compared a psychological therapy to a control group. No study compared psychological therapies to medications or medications in combination with a psychological therapy. There was fair evidence for the effectiveness of psychological therapies, particularly CBT, for the treatment of PTSD in children and adolescents for up to a month following treatment. More evidence is required for the effectiveness of psychological therapies in the longer term and to be able to compare the effectiveness of one psychological therapy to another. The findings of this review are limited by the potential for bias in the included studies, possible differences between studies which could not be identified, the small number of identified studies and the low number of participants in most studies.

Introduction. Although the symptom presentation of PTSD in the general and military population is very similar, combat-related PTSD is typically thought to be more severe due to the repeated and prolonged exposure of traumatic events. One of the treatments of choice, Eye-Movement Desensitisation and Reprocessing (EMDR) has however not been validated for the military population.

Method. A meta-analysis was carried out on literature ranging back to 1987.

Results. The analysis thus far resulted in a failure to support the effectiveness of EMDR in treating PTSD in the military population. Several possible explanations are given, of which the limited amount of well-designed RCTs seems to be the most important one.

Conclusion. Until more research is done, EMDR as first treatment of choice for combat-related PTSD should only be used if other treatment protocols have proven unsuccessful.